HospitalInspections.org

Based on policy review, medical record review, and staff interviews the hospital nursing staff failed to document a complete nursing admission assessment on post-operative surgical patients for 3 of 6 patients (Patient #12, Patient #14, Patient #22), and failed to document post-operative vital signs per physician orders on 2 of 6 patients (Patient #14, Patient #22).

Findings included:

1. Review of the hospital policy titled "Assessment/Reassessment Dimensions" revised November 2017 revealed "SCOPE/PURPOSE, Patients are assessed to determine their past/current physical, functional and psychosocial status to identify the appropriate care, treatment and services needed...B. Patients requiring nursing care will have admission assessments by an RN (Registered Nurse) initiated...and will be completed within 4 hours of inpatient admission. This assessment provides the basis for establishment of the patient's plan of care....D. Patients will receive a full/complete assessment by an RN...3. When patient is transferred from one level of care to another level of care...VII. DEFINITIONS...Admission Assessment completed by the RN...includes but is not limited to the following components: ...Full/Complete Assessment..." Vital Signs...Full Complete Assessment: Physical Assessment - Collection/Analysis of...Review of body systems...Functional Assessment: Ability to perform an action in manner or range consistent the purpose of an organ or organ system...Vital Signs comprise of temperature[T], pulse [P], respirations [R], and blood pressure [BP]. Vital Signs are obtained on admission..."

a. A closed medical record review 11/03/2020 on Patient #12 revealed a 47-year-old admitted for elective L-4-L5 Posterior Lumbar Interbody Fusion with Instrumentation (Lower Back Surgery) on 07/08/2019 at 0916. Review of the Post Anesthesia Care Unit record revealed Patient #12 was transferred to the surgical unit at 1507. Review of the Admission Nursing Assessment dated 07/08/2019 at 1530 revealed no admission vital signs. Review of the Nursing Flowsheet revealed vital signs were taken the first time on 07/08/2019 at 1611 by CNA #2. Review of the record revealed that vital signs were not included in the admission nursing assessment. Review failed to reveal an appropriate admission nursing assessment for Patient #12 per policy.

Request on 11/05/2020 to interview the nurse who received Patient #12 from PACU revealed she was unavailable.

Interview on 11/06/2020 at 1210 with Nursing Unit Manager, RN #6 revealed that nurses are expected to follow policy and procedure for completion of admission nursing assessment. Interview revealed that vital signs are a part of the admission nursing assessment. Interview revealed that RN #5 did not document a complete admission nursing assessment on Patient #12.

b. A closed medical record review on 11/03/2020 revealed Patient #14, a 56-year-old who was admitted for elective Bilateral Posterior Cervical Laminectomy for C2-C7 (Neck Surgery) on 11/02/2020 at 0807. Review of the Post Anesthesia Care Unit record revealed Patient #14 was transferred to the surgical unit at 1424 received by RN #5. Review of the Nursing Admission Assessment by RN #5 dated 11/02/2020 at 1452 revealed no body system assessment present for respiratory, cardiac or vital signs. Review failed to reveal an appropriate admission nursing assessment for Patient #14 per policy.

Request on 11/05/2020 to interview the nurse who received Patient #14 from PACU revealed she was unavailable.

Interview on 11/06/2020 at 1210 with Nursing Unit Manager, RN #6 revealed that nurses are expected to follow policy and procedure for completion of admission nursing assessment. Interview revealed that vital signs are a part of the admission nursing assessment. Interview revealed that RN #5 did not do a complete admission nursing assessment on Patient #14.

c. A closed medical review on 11/03/2020 revealed Patient #22, a 76-year old who was admitted for elective Decompression of L-4-5 (Lumbar) Fusion (Lower Back Surgery) on 10/27/2020 at 0719. Review of the Post Anesthesia Care Unit record, Patient #22 was transferred to the surgical unit at 1401 received by RN #7. Review of the Nursing Admission Assessment dated 10/27/2020 at 1418 by RN #7, revealed no body systems assessment for respiratory and cardiac present. Review failed to reveal an appropriate admission nursing assessment for Patient #22 per policy.

Interview on 11/06/2020 at 1145 with RN #6 revealed "an Admission Assessment should include a head to toe assessment including heart and lungs." The interview revealed that the admission nursing assessment for Patient #22 on 10/27/2020 at 1418 was incomplete.

Interview on 11/06/2020 at 1210 with Nursing Unit Manager, RN #6 revealed that nurses are expected to follow policy and procedure for completion of admission nursing assessment. Interview revealed that RN #7 did not document a complete admission nursing assessment on Patient #22 per hospital policy.

2. Review of the hospital policy titled "Assessment/Reassessment Dimensions" revised November 2017 revealed "SCOPE/PURPOSE, Patients are assessed to determine their past/current physical, functional and psychosocial status to identify the appropriate care, treatment and services needed...3. When patient is transferred from one level of care to another level of care...VII. DEFINITIONS...Admission Assessment completed by the RN ...includes but is not limited to the following components: ...Full/Complete Assessment...Vital Signs...Full/Complete Assessment...Vital Signs...Full Complete Assessment: Vital Signs comprise of temperature[T], pulse [P], respirations [R], and blood pressure [BP].Vital Signs are obtained on admission..."

a. A closed medical record review on 11/03/2020 revealed Patient #14, a 56-year-old who was admitted for elective Bilateral Posterior Cervical Laminectomy for C2-C7 (Neck Surgery) on 11/02/2020 at 0807. Review of Physician Orders for Patient #14 by a surgeon, MD #3, dated 11/02/2020 at 1431 revealed vital signs were to be obtained every 4 hours. Review of the Post Anesthesia Care Unit record revealed Patient #14 had a final set of vital signs taken at 1415 by RN #8 before being transferred to the surgical unit at 1424 received by RN #5. Review of the Surgical Nursing Vital Sign Flowsheet revealed the next set of vital signs documented for Patient #14 was at 1956 (5 hours and 32 minutes after transfer). Review revealed vital signs were not obtained per physician orders for Patient #14.

Request on 11/05/2020 to interview the nurse who received Patient #14 from PACU revealed she was unavailable.

Interview on 11/06/2020 at 1210 with Nursing Unit Manager, RN #6 revealed that nurses are expected to follow physician orders per. Interview revealed that RN #5 did not follow physician orders for Patient #14, in maintaining vital signs every 4 hours.

b. A closed medical review on 11/03/2020 revealed Patient #22, a 76-year old who was admitted for elective Decompression of L-4-5 (Lumbar) Fusion (Lower Back Surgery) on 10/27/2020 at 0719. Review of the Physician Orders dated 10/27/2020 at 1351 by Surgeon/MD #4 for Patient #22 revealed for vital signs to be taken every 4 hours. Review of the Post Anesthesia Care Unit record revealed Patient #22 had a final set of vital signs taken at 1245 and was transferred to the surgical unit at 1401 received by RN #7. Review of the Surgical Nursing Vital Sign Flowsheet revealed the first set of vital signs documented on the floor for Patient #22 was 10/27/2020 at 1418 by Certified Nursing Assistant #1 (CNA). Review of the Nursing Vital Sign Flowsheet revealed vital signs were not taken again on Patient #22 until 10/27/2020 at 1952 (5 hours and 34 minutes after the previous set of vital signs). Review revealed vital signs were not obtained per physician orders for Patient #22.

Interview on 11/06/2020 at 1145 with RN #6 revealed "This patient should have had another set of vital signs." Interview revealed that physician orders for vital signs were not followed for Patient #22.

Interview on 11/06/2020 at 1210 with Nursing Unit Manager, RN #6 revealed that nurses are expected to follow physician orders. Interview revealed that RN #6 did not follow physician orders for Patient #22's vital signs.

NC00156339; NC00158230; NC00159338; NC00161487; NC00168219; NC00170234; and NC00170545